IntraPet Ultrasound Patient Information Form

To schedule:

TEXT: 410-849-6867 or

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DATE OF ULTRASOUND APPOINTMENT: CONFIRMED appointment indicates Hospital has agreed to pay Ultrasound exam fee or cancellation fees if applicable.

Confirmed with IntraPet and Owner

REQUESTED DATES for ultrasound (if not already confirmed with IntraPet, format: month/day). Any notes re appt may be added here

Hospital Name (No acronyms or #’s)

DVM Name

Pet Name

Owner Last Name

Date of Birth

Date

Weight (specify lbs or kg)

Over 95# may incur additional fees, please inquire at time of scheduling

Species/Breed

Sex

Ultrasound Exam-select all that apply. (Abdominal includes urinary & repro)

If Specialty or Procedure specify type:

(Urinary, Thyroid, Chest, Pregnancy, FNA)

Previous IntraPet Ultrasound?

Date of Previous IntraPet Ultrasound

PLEASE SPECIFY ECHO OR ABD

If concern for second cavity pathology is seen during a scan (ex: splenic mass, pleural effus, enlarged abd vess), a LIMITED screening for pericardial effusion or heart based mass only is approved for $50

Presenting Complaint/History/PE

GRADE OF MURMUR REQUIRED IF ECHOCARDIOGRAM

Tentative diagnosis/ Questions to be answered with ultrasound

Brief abnormalities for Lab Results/Radiograph Findings (please upload full results or email intrapetstaff@gmail)

*INCLUSION OF ENTIRE MEDICAL CHARTS/VISIT NOTES ETC WILL RESULT IN ADDITIONAL FEES.

Medications with dosage and duration

Sedation is NOT a requirement, it is recommended with some patients to achieve a diagnostic ultrasound, but it is ultimately the decision of DVM and the owner. *Certain sedatives interfere with echocardiograms, please contact us with any questions scan or injection.

Sedation— any instructions can be listed in box below

Sedation: please type dosages (or “in medical chart”) and any information regarding sedation.

SEDATION DOSES MUST BE AVAILABLE AT THE TIME OF THE SCAN HERE OR IN MEDICAL RECORD

For approximate eta window: WE WILL NOT CALL A VOICE CALL NUMBER, please enter a TEXT or EMAIL ONLY. The sonographer will notify staff when they enter the hospital. This eta window is not guaranteed. Add-ons, cancellations and traffic affect our eta. Intramuscular sedation must have contact info entered here.

*PATIENT MUST HAVE BEEN DROPPED OFF IN HOSPITAL BEFORE 8 AM.

PLEASE NOTE: All patients must be dropped off by 745 am (Before 7AM for ERS) unless prior arrangements have been made at the time of scheduling.

Please inquire about for non-drop off scans if you have special circumstances, additional fees are charged for any patients that have not been dropped off in am.

Thank you!!

Confidential questions/concerns, information for specialist/sonographer. WILL NOT APPEAR ON FINAL REPORT

Lab work / Rads

Yes, employee pet No, not employee pet* Employee name matches patient name.

Same day report is approved if emergency and patient is in critical condition. (Same day reports are 2-6 hours after the scan has been completed)

Please enter your Email to receive a PDF copy of this form for your records. Your form will be editable from the link you receive at this email.

example@example.com

Secondary email if above email is not clinic email.

example@example.com

I have contacted IntraPet by text or separate email to schedule this exam:

TEXT/CALL 410-849-6867 or EMAIL intrapetstaff@gmail

THANK YOU!

IntraPet Patient Information